The public healthcare system in South Africa must be completely overhauled if NHI is to succeed.
This was the message from the Minister of Health, Dr Aaron Motsoaledi, on the first morning of the Board of Healthcare Funders' Southern Africa conference, currently being held in the Champagne Sports Resort in the Drakensberg.
The Minister bemoaned the fact that the country still has two healthcare systems: public and private.
“It is not the aim of the NHI to abolish private health, but to make sure that two systems are able to work in synergy. The fragmentation has to be dealt with,” he said.
Dr Motsoaledi pointed out that, according to the World Health Organisation's 2008 report on world health, there are three trends that undermine the improvement of health outcomes globally.
These are:
· Hospital centrism, which has a strong curative focus;
· Fragmentation in approach which may be related to programmes or service delivery; and
· Uncontrolled commercialism which undermines the principles of health as a public good.
“In South Africa we are dealing with all three,” he said.
When he spoke of uncontrolled commercialism, the Minister was careful to point out that he was not pointing fingers at the private healthcare system.
“In the public sector we have replaced a healthcare system with a tendercare system. Tenders come first, health comes later. Everyone knows that in our healthcare system commercialism comes first.”
In his presentation, the Minister reminded delegates that the NHI is based on seven main principles.
First is the constitution, which states that no one may be refused emergency medical treatment.
The other six principles are social solidarity, equity, appropriateness, effectiveness, efficiency and
affordability.
“Our current system does none of these things,” he said.
Dr Motsoaledi announced a number of measures to improve the public health system.
Flagship projects include a new medical school in Limpopo (the 9th in the country), a new George Mukhari Academic Hospital and a new structure for the Chris Hani Baragwanath Hospital.
The government also plans to spend R1.2 billion to revitalise nursing colleges.
“Our nursing colleges were not abolished but they were ignored. This was because in 1984 the government took the decision to train nurses in university. But now we say university can only come after basic training in college.”
Under NHI, health standards compliance will be mandatory. The Minister announced that he will be appointing an ombudsperson who will be a public protector in health and will “chase institutions if they give people a raw deal”.
“We need to re-engineer our primary healthcare system. Before end-of-year we will launch a school healthcare system which will focus on eyes, hearing, oral hygiene, immunisation, drugs and alcohol, reproductive health rights and HIV counselling and testing.”
The school system will be housed in a mobile unit which will travel between districts, providing access to primary healthcare.
“We have seen cases of school children in this country demanding abortions three times in six months. When we staged a fight against HIV, we threw family planning out of the window. It must come back.”
A National Health Commission will be established by March 2013 to deal with smoking, alcohol, diet, exercise, and motor vehicle accidents. The commission will be outside the Ministry of Health. It will fall under the Presidency and will be mandated to reduce the burden of disease and to make healthcare affordable.
Health Minister encourages private healthcare leaders with persuasive business case for NHI
A silent war has been declared on the people of South Africa and it is time for a ceasefire. The death rate has doubled in the nine years between 1997 and 2006. No other country on the planet outside of a war zone has experienced this, and the only way this trend will be reversed is through the provision of universal healthcare through the NHI.
This was the message from the Minister of Health, Dr Aaron Motsoaledi, on the first morning of the Board of Healthcare Funders' Southern Africa conference, currently being held in the Champagne Sports Resort in the Drakensberg.
The Minister made a persuasive business case for NHI, building on the presentation he gave at the BHF's 2011 conference. The underlying theme was one of working together to provide universal access to healthcare, and if anyone in the private healthcare industry was concerned about the role they had to play, they had good reason to be reassured.
For the delegates at the conference, one of the major preoccupations is the battle between the medical schemes and the Council of Medical schemes over Prescribed Minimum Benefits. The Minister emphasised that he was not taking sides on the issue.
“I am not here as a union of medical schemes” he said “But the PMBs is a terrible ruling. I don't think there is another area of life where there is so much uncertainty. How can it be possible that an invoice must be paid, regardless of the cost of that invoice?”
The Minister called for the Competition Commission ruling of 2004, which ruled that medical schemes could not collectively negotiate reimbursement tariffs with providers, to be changed.
“It is this ruling which has seen the number of medical schemes in South Africa drop by half; from 180 in 2001 to 99 today,” he said. “In private healthcare, anything goes because of the 2004 ruling.”
Dr Motsoaledi turned his attention to the pricing structures of the South African healthcare system. The World Health Organisation recommends that countries spend at least 5% of their GDP on health care.
“In South Africa we spend 8.5% of our GDP on health, but 5% goes to 16% of the population (8 million people) while 3.5% goes to 84% of the population (42 million people).”
Dr Motsoaledi also announced that a pricing commission will be established in 2013 so that pricing in the private healthcare sector will be regulated to be in line with the constitution.
“The pricing is abnormal and unacceptable, it must change. No medical scheme can survive when procedures that can be done by a medical student are costing R30 000, or R500 000. What happens? The schemes pay what they deem to be affordable and leave it up to the patients to pay the rest.”
“I am not about to blame the medical schemes, but under NHI this will not be allowed. Nothing must be demanded from the patient. No co-payments.”
“The solution does not lie in court cases. We need a law in parliament to cancel Regulation 8. That judgement is just going to increase health inflation in the country. It is going to force you to raise premiums. Joe Citizen will suffer whatever the outcome of the case.”
For Dr Motsoaledi, the only solution is the provision of universal health coverage. He pointed to the 1978 Alma Alta declaration, which aimed to improve the world's health. Twenty two years later, four of the eight Millennium Development Goals were dealing with the same issues.
“The pattern is that anything you declare in health doesn't become successful,” he said. “We who work in health have come to believe that the majority of healthcare systems around the world are wrongly designed. They are working for the wealthy but not for the world.
“The WHO's response is for universal health coverage. In South Africa our response is NHI.”
Dr Motsoaledi called on delegates to look at the NHI from the perspective of “what is in it for the country, for the citizens of South Africa, rather than what is in it for you as an individual.”
He reiterated the view of Dr Margaret Chan, Director General of the World Health Organisation who said at a meeting in Geneva in May this year that universal health care is “the ultimate expression of fairness”.
“Universal health coverage is the single most powerful concept that public health has to offer. Universal coverage is relevant to every person on this planet. It is a powerful equaliser that abolishes distinctions between the rich and the poor, the privileged and the marginalised, the young and the old, ethnic groups, and women and men,” she said.
For Dr Motsoaledi, the fact that South Africa emulates the US when it comes to healthcare provision is perplexing.
“Everything that is negative, we take on. I don't know why we have a tendency to bring all the sins of the world together in one place,” he said.
Relative to cost, South Africa has one of the world's worst performing healthcare systems.
“The reality is that most countries are spending less and getting better outcomes. And many of the countries who are outperforming us have NHI systems. Our system is based on that of the United States and their president says it is not working. There is no way we can leave the system like that,” he said.
In a comparison of BRICS countries, South Africa is second only to Brazil when it comes to expenditure on health as a percentage of GDP, but our life expectancy at birth is only 54. In Brazil it is 73, Russia 68, India 65 and China 74.
“The only area where we achieve better results than the rest of the world is in our low smoking figures,” he said.
According to a WHO report of 2008, the three trends that will undermine improvement in health outcomes are:
1. Hospital centrism, with a strong curative focus;
2. Fragmentation in approach which may be related to programmes or service delivery; and
3. Uncontrolled commercialism which undermines principles of health as a public good.
“In South Africa, we have all three,” he said. Adding to the problem is the fact that in South Africa we have a quadruple burden of disease. The Minister pointed to a Lancet report which showed that South Africa has twice the global average per capita burden of ill health. The country leads the world in terms of maternal and infant mortality, HIV/Aids and TB cases, non-communicable diseases and injuries and deaths caused by violence and injury.
“We need strategic leadership in every area,” he said. “I am appealing to you to work with us to provide the leadership we need to get the country out of this morass.”